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RheumaTutor. A case-based rheumatological training program. Stefan Schewe. ($50, DM 98, students$34.00, DM 68). Wiesbaden: Ullstein Medical Verlag, 1999. ISBN 3-86126-934-1 .
1. HEIN J BERNELOT MOENS
1. Medisch Spectrum Twente, PO Box 50 000, 7500 KA Enschede, the Netherlands

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Two interactive rheumatology tutors on CD-ROM

The widespread availability of information and communication technology offers new possibilities for education of professionals and of patients. One of these possibilities is computer assisted learning.1 Ten years ago, research focused on the development of computer assisted diagnosis and text based help to rheumatologists and others.2 Despite the initial enthusiasm about artificial intelligence (AI), resulting in several diagnostic expert systems, in routine care a precise diagnosis is rarely an important issue and as a consequence these systems are hardly used. The experience with expert systems, however, evolved into systems intended for educational purposes. “AI/Learn”, based on the “AI/Rheum” expert system and exploiting a videodisk with an image library, proved to be an effective means of teaching rheumatology.3 The same image library was used to teach occupational and physical therapy students with the “HP-Rheum” system (HP: Health Professionals).4 In recent years the introduction of sound, images, and movies on PCs, and the replacement of videodisks by CD-ROM facilitated production and access to these methods. The products resulting from the AI/Rheum project are not yet available on this medium, but two European rheumatologists have now completed educational systems on CD-ROM. They are to be honoured for their pioneering efforts. The main characteristics of the systems are summarised in table 1, details are discussed below.

Table 1

Main characteristics of the two CD-ROM tutors

The widespread availability of information and communication technology offers new possibilities for education of professionals and of patients. One of these possibilities is computer assisted learning.1 Ten years ago, research focused on the development of computer assisted diagnosis and text based help to rheumatologists and others.2 Despite the initial enthusiasm about artificial intelligence (AI), resulting in several diagnostic expert systems, in routine care a precise diagnosis is rarely an important issue and as a consequence these systems are hardly used. The experience with expert systems, however, evolved into systems intended for educational purposes. “AI/Learn”, based on the “AI/Rheum” expert system and exploiting a videodisk with an image library, proved to be an effective means of teaching rheumatology.3 The same image library was used to teach occupational and physical therapy students with the “HP-Rheum” system (HP: Health Professionals).4 In recent years the introduction of sound, images, and movies on PCs, and the replacement of videodisks by CD-ROM facilitated production and access to these methods. The products resulting from the AI/Rheum project are not yet available on this medium, but two European rheumatologists have now completed educational systems on CD-ROM. They are to be honoured for their pioneering efforts. The main characteristics of the systems are summarised in table 1, details are discussed below.

This CD is dedicated to education and has won several awards. It uses text, images, sound, and video. The first time user receives clear instructions, and is invited to browse a wide variety of materials and subjects. The interface is straightforward and easy to use.

The materials can be accessed using keywords and text search, or by structured menus. The program provides excellent instructions on history, physical examination, and local injections. Although information on specific diseases is included, methodological topics have more emphasis. This property makes the system particularly useful as an educational tool for medical students, general practitioners, or for paramedical personnel working in rheumatology units. For rheumatologists the CD-ROM is fun to look around, but it is not intended to and cannot replace a textbook at a specialist level.

The quality of the photographs and radiographs is excellent. The video captures are presented in a small window, but do suffice to illustrate physical examination or local injections. There are 10 amusing quizzes, of adequate difficulty for final year medical students or specialist trainees. The CD-ROM is also equipped with a glossary, a set of patient problems presented in a hospital clinic or in a general practitioners' office, and an “Arthritis Expert”. The latter is an elementary expert system that can generate diagnostic hypotheses.

In our hospital final year medical students are now using theRheumatology Tutor during the five day rheumatology course. They are given an instructions sheet to get them started on the first day. The first group enjoyed the program, and agreed that it was a more efficient introduction to rheumatology than a textbook or than instructions by a busy specialist during an outpatient clinic.

A drawback of the system is that it aims at a wide view of rheumatology and therefore is vulnerable for inconsistencies or details about which different opinions may exist. In an earlier review, for example, the different names of drugs between the US and the UK were mentioned as a minor disadvantage.5

This CD-ROM is centred on a set of 25 cases with various rheumatic diseases. The user-interface has a common format, but it takes a couple of cases to learn to navigate through the program.

Cases may be selected from a list, or be chosen randomly by the system. A patient is presented with a chief complaint and data on age, sex and profession. The student is asked to select further questions from a standard list. Subsequently, physical examination is mimicked by photographs of hands, feet, or other parts of the body. The user marks interpretations in standard lists of findings or on a figure, a process that is critiqued and scored by the system. Both correct and incorrect answers are explained and illustrated. The same process is repeated for radiological interpretation, laboratory testing, differential diagnosis, and therapeutic advice. The system's critiquing is supported by texts, based on the Quality Guidelines of the German Rheumatological Association. The quality of photographs and radiographs is adequate for the purpose of the program.

The degree of difficulty in the cases makes it suitable only for students who have at least basic knowledge of rheumatology. Even for an experienced rheumatologist it is hard to obtain the maximum scores. This is because of the degree of detail in which the system requires answers, which also slows down the process of going through a case.

This program is limited to case-based teaching. It lacks direct access to instructions on physical examination or interpretation, although the critiquing by the system substitutes for this. As a consequence of its architecture, originally based on an expert system, it uses long lists of possible signs and symptoms, which are sometimes cumbersome to work with. The author solved this by clustering findings into groups, which can be unfolded by clicking on them.

On the positive side, the system forces the student to observe accurately whatever can be seen, and provides adequate corrections for misinterpretations and funny rewards for the user's efforts. The scoring method, including rewards for cost effectiveness, is interesting, although it is not easy to see how a particular score was reached. A majority of German students evaluated the system positively, as long as it was part of a clinical course.6 It is sad that an official version of the system is only available in German, which limits its use to speakers of that language (an unofficial English translation is available from the author).

## Conclusion

These CD-ROM tutors illustrate both the vast potential and the wide range of possibilities offered by multimedia computers. From a practical point of view, Armstrong's Rheumatology Tutor is the most useful tool for medical students. As an adjunct to an elective week it can help to fill the gaps that generally exist in training based on outpatient clinics or ward rounds. As a case-based tutor, the technology of Schewe's program is more interesting. However, I would prefer the latter to focus less on detail and more on common symptoms. Also, the inclusion of instructions in the form of video-clips would make it even better suited to the needs of medical students.

These CD-ROMs mark the beginning of a new era of education in rheumatology. They will complement clinical teaching, but—despite my enthusiasm—I do not believe that they will replace it!

Two interactive rheumatology tutors on CD-ROM

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